Some links and readings posted by Gary B. Rollman, Emeritus Professor of Psychology, University of Western Ontario

Sunday, January 10, 2010

The Wrong Story About Depression - NYTimes.com

"Startling results," promised the CNN teasers, building anticipation for a segment on this week's big mental health news: a study led by researchers at the University of Pennsylvania indicating that the antidepressants Paxil and imipramine work no better than placebos ("than sugar pills," said CNN) for people with mild to moderate depression.

Happy pills don't work, the story quickly became, even though, boiled down to that headline, it was neither startling nor particularly true.

It sounded true. After all, any number of experts have argued that antidepressants — and selective serotonin reuptake inhibitors like Paxil in particular — are overhyped and oversold. And after years of hearing about shady practices within the pharmaceutical industry, and of psychiatrists who enrich themselves in the shadows by helping the industry market its drugs, we are primed to believe stories of psychiatric trickery.

Yet in all the excitement about "startling" news and "sugar pills," a more nuanced and truer story about mental health care in America was all but lost.

That story begins to take shape when you consider what the new study actually said: Antidepressants do work for very severely depressed people, as well as for those whose mild depression is chronic. However, the researchers found, the pills don't work for people who aren't really depressed — people with short-term, minor depression whose problems tend to get better on their own. For many of them, it's often been observed, merely participating in a drug trial (with its accompanying conversation, education and emphasis on self-care) can be anti-depressant enough.

None of this comes as news to people who have been prescribing or studying antidepressants over the past 20 years. Neither is it all that likely to change the practice of treating depression — at least as it's carried out by responsible doctors.

After all, people who are depressed for the first time, or have been depressed for only a short time, or are upset after a personal setback, aren't considered ideal candidates for immediate drug therapy. And, contrary to popular belief, there's no evidence that most psychiatrists regularly prescribe pills straight off to people who can get better by reading about depression, exercising or doing nothing. What numbers do exist, said Peter Kramer, who has written extensively on antidepressant use in books like "Listening to Prozac," indicate that relatively few people with minimal depression leave psychiatrists' offices with a prescription.

That people have come to believe otherwise may be in part because most patients with depression are treated by general practitioners, not psychiatrists. Studies have shown that these primary care doctors don't strenuously enough screen their patients for depression before prescribing drugs, or closely monitor their care afterward.

And here the truer story about mental health care in America begins to unfold. The trouble is not that the drugs don't work; it's that the care is not very good.

Inadequate treatment by nonspecialists is only a piece of the problem. In fact, most Americans with depression, rather than being overmedicated, are undertreated or not treated at all. This might have been big news this week, too, had anyone noticed another academic study, a survey of nearly 16,000 people published this month in The Archives of General Psychiatry, which looked more broadly at the picture of depression in America. The survey found that those who did get care were given psychotherapy more often than drugs. That finding might give heart to those who would prefer to see more alternatives to psychiatric drugs — if it weren't for the fact that so much psychotherapy is so bad.

In 2008, a team of psychologists brought this point home in blunt terms in the journal Psychological Science in the Public Interest. "Despite the availability of highly effective interventions," they wrote, "relatively few psychologists learn or practice these interventions."

This is the big picture of mental health care in America: not perfectly healthy people popping pills for no reason, but people with real illnesses lacking access to care; facing barriers like ignorance, stigma and high prices; or finding care that is ineffective.

It is a societywide concern that a co-author of the new antidepressants study readily acknowledges. "What we reported on was a very small piece of a very large problem," Robert J. DeRubeis, a professor of psychology at the University of Pennsylvania, told me. "Those kinds of things are not being sorted out in this country because there's no system. Nobody's asking these questions."

With health care reform almost certainly on the horizon, perhaps now we can hope they will start asking.

Judith Warner, a former columnist at nytimes.com, is the author of the forthcoming "We've Got Issues: Children and Parents in the Age of Medication."